new england journal



Surgical Correction of Cleft Lip and Palate
to the editor: Interplast, a nonprofit organization
providing free reconstructive plastic surgery to children around the world, agrees with Dr. Mulliken in
his Perspective article (Aug. 19 issue)1 that children
in developing countries who undergo surgery for
cleft lip and palate should receive the highest-quality medical attention and proper continuity of care.
However, his portrayal of our work is outdated. The
changes he suggests have already been successfully
implemented. Developing medical independence so
that the poor have access to the reconstructive care
they require year-round — and for generations to
come — is our goal. Educating, empowering, and
building local surgical capacity with overseas medical partners is Interplast’s focus. Last year, visiting
educators conducted workshops at 14 sites.
Interplast international medical partners perform the volume of operations necessary to maintain both competency in the repair of cleft lip and
palate and optimal year-round care. The center in
Nepal treated 3000 patients in its first three years
and provides follow-up care, as well as auxiliary services; its director, Dr. Shankar Man Rai, was recently honored as outstanding international physician
by the American Medical Association. Although Interplast also provides direct services with trips by
volunteer surgical teams, these groups of competent surgeons return year after year to the same sites,
providing follow-up care and medical training.
William J. Schneider, M.D.
D. Scott Corlew, M.D.
Mountain View, CA 94041
1. Mulliken J. The changing faces of children with cleft lip and pal-

ate. N Engl J Med 2004;351:745-7.

to the editor: I would take issue with Dr. Mulliken’s assessment of volunteer groups that travel to
developing countries to repair cleft lips and palates
in children. Discouraging donations to these programs does a disservice to the children who would
otherwise lack access to surgical care.
I traveled with Interplast, providing pediatric
support to the surgical team. The surgery was skillfully accomplished. Local health care providers were
involved in delivering care and learning alongside
the Interplast team. Follow-up is not perfect in areas


n engl j med 351;25

where dental, ear-nose-and-throat, and speech care
is not available, but the surgery makes the patient
cosmetically and socially acceptable. The need outstrips resources in developing countries. Teams set
an example for volunteerism and are ambassadors
of goodwill. They provide valuable service, and the
personal experience adds to their compassion and
understanding as physicians. The families are intensely grateful for the help. American families
should not discount experience gained internationally in choosing a cleft-lip-and-palate surgeon. Donors can be confident that their funds support essential care and vastly improve the future for needy
Eugenia Marcus, M.D.
Pediatric Health Care at Newton Wellesley
Newton, MA 02462-1602

dr. mulliken replies: Dr. Marcus suggests that
parents should not disregard operative experience
gained in other countries when choosing a surgeon
to repair their child’s cleft lip or palate. I cautioned
parents to select a surgeon who is active in an established cleft team, rather than one who operates on
clefts, primarily and periodically, overseas.
I agree with Dr. Marcus that volunteer care for
children with cleft lip and palate in other countries
rekindles the wonderful feeling of being a physician. To treat a person without regard for a fee is the
purest form of medical practice. Without question,
children benefit from these humanitarian missions,
but their number is finite. Furthermore, once the
team departs, the local health care system usually
fails to provide the necessary follow-up services for
speech, dental care, and otology — and nothing
changes. In contrast, large U.S.-based nonprofit organizations, such as Interplast and the Smile Train,
are helping to establish independent cleft centers
in developing countries,1 as noted by Drs. Schneider
and Corlew. However, there are many other, smaller groups that continue to operate under the old
paradigm of “itinerant surgery.”
Dr. Marcus believes my Perspective article discourages donations to volunteer groups. Rather,
I underscored that donors, both individual and
corporate, should be aware of the differing philos-

december 16, 2004

The New England Journal of Medicine
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Copyright © 2004 Massachusetts Medical Society. All rights reserved.

25 Table 1. Lancet 2004. All rights reserved. their contentions that it is now unacceptable to use methotrexate alone in the control group in a randomized trial and that the combination of methotrexate and TNF inhibitor “might . www. Therefore. Corbett M. Vaiani M. and the increase in the number of children helped would be exponential.2 He calculates that the cost per operation. O’Dell JR. He notes that although the operations performed by foreign teams are free for the family. Effect of a treatment strategy of tight control for rheumatoid arthritis (the TICORA study): a single-blind randomised controlled trial.350:2167-79. 26 issue)1 sum- marize the evidence supporting the use of a combination of methotrexate and tumor necrosis factor (TNF) inhibitor over methotrexate alone in patients with rheumatoid arthritis..correspondence ophies and goals among the various organizations so that they can decide how best to dispense their largesse. of DMARDs before Trial Drug Failure Required for Inclusion* Weinblatt et al.nejm. working with local surgeons. Thus.B. † Data were reported by Olsen and Stein. N Engl J Med 1996. John B. de Jager JP. and he proposes that the funds be used to cover the expense of procedures performed by well-trained local surgeons. et al. usually methotrexate (Table 1).106:886-9. For 30 years.363:67581. N Engl J Med 2004. Children’s Hospital Boston Boston. Teach a man to fish and you feed him for a lifetime. et al. Roberts. Capell H.6 is substantially cheaper. N Engl J Med 2004. Australia n engl j med 351. TNF inhibition is unnecessary and has not been studied.113:433-5. Christian Dupuis. M. Haire CE. Publication Year Average No.7 Methotrexate Weinblatt et al.3 (including methotrexate in 42%) One DMARD (not methotrexate) Study * The inclusion criteria required patients to have rheumatoid arthritis.† 1999 2. Ann Rheum Dis by niniadiany ansari on October 29. In one third of untreated patients with rheumatoid arthritis. Baseline Characteristics of Patients in Trials of Disease-Modifying Antirheumatic Drugs (DMARDs). M.5 2004 2. Therapeutic effect of the combination of etanercept and methotrexate compared with each treatment alone in patients with rheumatoid arthritis: double-blind randomised controlled trial. Rai SM. Plast Reconstr Surg 2000. 3. However.4 1. 6. 334:1287-91. Mulliken. or a combination of all three medications. New drugs for rheumatoid arthritis.8 Methotrexate Maini et al.” But the teacher should be skilled at fishing. a Belgian plastic surgeon. for the treatment of rheumatoid arthritis. Klareskog L. Copyright © 2004 Massachusetts Medical Society. Messori A. and has not been directly compared with methotrexate–TNF-inhibitor combinations. Stein CM. Ph. combination DMARD treatment without TNF inhibitors is highly effective..D. Plast Reconstr Surg 2004. Grigor C. Olsen NJ. . 2004 The New England Journal of Medicine Downloaded from nejm. Humanitarian missions in the Third World: a polite dissent.0 Methotrexate and one other DMARD Klareskog et al. Lynden J. B. be considered as standard therapy for patients with rheumatoid arthritis” are not supported by evidence. for the same amount of money. 4.† 1999 2. Furthermore. MA 02115 1. the donors’ monies probably are not well spent.364: 263-9. Dingman DL. Brook A.2 In these patients.D. in patients whose disease is resistant to a DMARD. has spent 1 to 2 months a year in Southeast Asia. Royal Melbourne Hospital Parkville 3050.36:71-3. et al.S. sulfasalazine and hydroxychloroquine. Dupuis CC. in Western dollars.† 2003 3. is enormous.4 The results of these trials may not apply to groups of patients who have not yet been studied. No other uses without permission. New drugs for rheumatoid arthritis. Lancet 2004. the number of operations would increase 10-fold. Remember the old Chinese proverb: “Give a man a fish and you feed him for a day. For personal use only. despite prolonged use of methotrexate or another DMARD. Treatment of rheumatoid arthritis with methotrexate alone.351:937-8. Establishing cleft malforma- tion surgery in developing nations: a model for the new millennium. van der Heijde D. New Drugs for Rheumatoid Arthritis to the editor: Messori et al. Zbar RIS. Radiographic changes in early rheumatoid disease. Randomized trials of TNF inhibitors have included only the half 3 of all patients with rheumatoid arthritis who do not have a response to at least one disease-modifying antirheumatic drug (DMARD). 2. Stirling A. 5. current evidence suggests that TNF inhibitors provide a useful addition to our medical armamentarium. Santarlasci B. rather than a panacea. ( december 16. 2014. progressive joint destruction does not develop. 2659 . . 2. Erikson N.